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90-1314
EnvironmentalHealth
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4200/4300 - Liquid Waste/Water Well Permits
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90-1314
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Last modified
1/21/2020 10:11:27 PM
Creation date
12/3/2017 5:28:39 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
90-1314
STREET_NUMBER
20008
Direction
S
STREET_NAME
NAGLEE
STREET_TYPE
RD
City
TRACY
SITE_LOCATION
20008 S NAGLEE RD
RECEIVED_DATE
6/1/90
P_LOCATION
N A BALDOCCI FARMS
Supplemental fields
FilePath
\MIGRATIONS\N\NAGLEE\20008\90-1314.PDF
QuestysFileName
90-1314
QuestysRecordID
1866690
QuestysRecordType
12
Tags
EHD - Public
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r 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address t/`-'@O0 City Lot Size PM <br /> Owner's Name AW i_.A, _q Address d3 • Phone <br /> Contractor -EoAddress ;0�ce _ <br /> /� f ��License No. 46 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .. <br /> *omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other 71 Delta Depth of Grout Seal Type of Grout_ <br /> I i Irrigation -Approx. Depth i I Eastern Surface Seal Installed by <br /> .� <br /> Repair Work Done Ll Type of Pump e4H.P.3 State Work Done p <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 __ G <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is 00 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal C� <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c I f r all required - spections. Complete drawing on reverse side. <br /> Signed X � Title: �iC P.�- Date: <br /> FOR,41EPARTMENT USE ONLY <br /> Application Accepted by A�tDate _�6� . Area <br /> Pit or Grout Inspection by Date Final Inspection b g 4 Date �o Q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 <br /> CASH F RECEIVED BY DATE PERMIT NO. <br /> a EH 13-24 IREV.i i n 51 <br /> EH 14-26 - p <br />
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